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NIFIED PROGRAM CONSOLIDATED FORD" PR#:PR0231848 FAC#:FA0002052 UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDE �{' D PERMIT spccify change local ase Daly.= ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 3505 NAVY DR.STOCKTON BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Busincss As) 3 FACILITY ID# PR ID# ST SERVICES FA0002052 PR0231848 1 NEAREST CROSS STREET aol FACILITY OWNER TYPE E]4.LOCAL AGENCY/DISTRICT• -NAAW if" ® 1.CORPORATION ❑5.COUNTY AGENCY' BUSINESSC] 2.INDIVIDUAL E] 1. STATION ❑3.FARM ❑ 5.COMMERCIAL C]6.STATE AGENCY' TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY' 402 TOTAL NUMBER OF TANKSIs facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 404 ❑ Yes ® No 005 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME (� 407 I PHONE 408 972 931-8065 MAILM OR STREET ADDRESS 409 R , ox -76033 CITY 410 STATE alt ZIP CODE / 412 -Bt4 Ars• AIr-J �I N �Q� i C� Tx 2 $_Z b PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL 1:14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ❑3.PARTNERSHIP [:15.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME ala PHONE 415 ST SERVICES 209 943-5662 MAILING OR STREET ADDRESS 416 2941 NAVY DR CITY 417 1 STATE alg ZIP CODE 419 STOCKTON CA 95206 TANK OWNER TYPE © 1,CORPORATION ❑2.INDMDUAL [14.LOCAL AGENCY/DISTRICT 1:16.STATE AGENCY 420 ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-000400 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) © 1.SELF-INSURED 1:14.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 1-12.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 1-199.OTHER 1:13.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 4" VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ® 1.FACILITY 1:12.PROPERTY OWNER ❑3.TANK OWNER 42' Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE Certification-1 certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 42a PHONE 41; (972)931-8065 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local w ml,) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use cdy) 4229 Is 1998 Compliant?Y UPCF(1/99 revised)